It’s Not About The Box Improving Care at Group Health with People, Process and Technology

September 23, 2011

Shared Decision Making in DC

Filed under: Shared Decision Making — Matt Handley @ 4:59 am

I am at a shared decision making conference in DC  – day 2

Shannon Brownlee, great writer and speaker and author of “Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer” – is leading off the day.  A compelling writer, she started with a story.  A patient with panic attacks that eventually ends up with an angiogram to “just be sure”, despite a very low pretest probability, and after her angiogram looks fine she has a serious complication that leads to cardiac arrest and now serious long term health problems.  A high price to pay for reassurance.  The combination of a passive patient, physicians who did not listen to her whole story, and an over-reliance on technology.

OK – so everyone in the room is hooked

She shared a report that I was not aware of – The California Healthcare Foundations analysis of variation in procedure rates across California.  Important work that extends the idea of the Dartmouth Atlas (which uses Medicare data) to younger populations.  No surprise that there is dramatic variation across the state in most everything.  The researchers have also adjusted for income, race/ethnicity, and CVD risk (using MI and DM as proxies).  There is a great interactive map that you should check out.

This is really an effort to inform three audiences – policy makers/payors, doctors and patients.  We will have to invest in all three groups to work to diminish the variation and have it be driven mostly by clinical circumstances and patient preference

September 19, 2011

New Developments in our Electronic Medical Record

Filed under: Electronic Chart,MyGroupHealth — Matt Handley @ 9:10 am

I am in Madison, Wisconsin, at the Epic User Group Meeting (UGM).  It is always a great event, mostly because it brings together innovative leaders from most of the highest performing group practices in the US.  Today is the Physician Advisory Council (and there are many concurrent council meetings, including nursing and pharmacy, with overlapping topics) and one theme has already emerged throughout the AM talks.  Involving patients more actively.  Great to see!  I am in a session now about having an online questionnaire linked to well visit checks, that makes things easier for both patients (well, their parents) and for clinicians.  Moving work to the time and place it fits best, rather than forcing everything to happen at an in-person visit.

Imagine having pre-visit questionnaires for well visits and for selected visits for chronic illness.  More participation, more convenience.  And then imagine people being able to access their medical record – and their doctor – through their smartphone – oh – we already do that through our iPhone app!

July 28, 2011

A Different Kind of Checklist Experience

Filed under: Safety — Matt Handley @ 3:25 pm

I think that personal experiences reinforce theoretical concepts much more powerfully than readings, lectures or the stories of others. No matter how many great anecdotes Atul Gwande included in his excellent book “The Checklist Manifesto” , a personal experience will always drive home the point more effectively.

My checklist experience wasn’t relating to a medical adventure – I did not experience the use of a checklist associated with a medical procedure.   My checklist experience was a part of a family adventure.

My daughters have wanted to go bungee jumping since they watched me bungee jump in New Zealand many years ago. This summer my youngest turned 18, and we decided that the best celebration would be to take the family bungee jumping (with my wife just watching, the sensible one). We went to a great site in southern Washington state and had a marvelous experience there.  A 191 foot drop over a small creek.   The crew there does everything right. The roles and responsibilities of every one on the team are clearly understood, the check list for harness and attachment to the bungee is independently checked by 2 different crew members before you’re ready to jump, and then double checked again prior to the jump. They are unabashed about calling out the specific items they’re checking, naming and touching and testing each part of the harness and attachment.

My daughters had a great time, each jumping twice, first facing forward and and then facing backwards.  Weighing considerably more than my daughters, I followed after the bungee cord was switched to one of more considerable heft.  They went through the checklist with the same rigor, and I had a great time leaping far out on the first jump.  There are two remarkable feelings when you bungee jump.  The first is the feeling of having your adrenal glands become the size of raisins – lots of adrenaline. The second is when the body starts to slow and your mind recognizes that you are not going to hit the bottom and you bounce back up, at this location probably 70-100 feet back up.  It’s a marvelous feeling.   After I had been winched back up after the first jump, they asked me to step over the railing rather than do my second jump.   The supervisor had heard something that might indicate a problem.   They ran through everything again, including checking through every bit of the bungee cords to make sure that things were sound.  I was surprised to find that this interruption was reassuring rather than worrisome.   Nothing was wrong with the bungee or the attachments, but because someone had heard something that might have indicated a problem they stopped the process and rechecked the equipment completely before proceeding.    Then back to play – I got to do the backwards jump, which was pretty incredible.

It was an interesting experience from a safety perspective.   While there were some jokes made about adventures sports and the risks we were taking, it was clear from their processes that this was really the illusion of danger, and all of the activities of the crew were organized around safety.   No one thought that the participants  needed to be insulated from the crew’s concern about safety, and they led with that (although they did accompany it with a healthy dose of entertainment).  Substitute care and concern for entertainment, and that’s a great model for us in medicine.

I can’t post about bungee jumping without adding two photos of the adventure.  The leap out, and the moment of unweighting as you are heading back up after the first “bounce”.

The Jump

The Happiness of Floating

March 25, 2011

Innovating through Engagement

Filed under: Uncategorized — Matt Handley @ 1:31 pm

What is possible when we have engagement – within the clinical team and with patients?   At the Group Health “Innovating Through Engagement” conference, stories are being told that suggest that the answer is – most anything.

The day focuses conversations on a few innovations that Group Health has been successful with.  Those of us who have been involved in them tend to see them as yesterday’s news – we forget how unusual and special these efforts have been, and how much our patients and the organization have benefited from them.

The Patient Centered Medical Home (Health affairs article summarizing the 2 year outcomes  health affairs ghc medical home )  what happened there – better care, happier patients, more engaged staff and lower costs.

EDHI – comprehensive strategy to reduce both hospitalizations and readmissions – resulting in benchmark performance on hospital days

Shared Decision Making for Preference Sensitive conditions  (older posts about this one, my favorite, here and here )  We now have the largest implementation of video decision aids in the country, leading to better care, happier patients and lower costs

Improving the Value of High End Imaging  (older posts here and here ) – same story – better care and lower costs (for the last 4 months the rate of ordering of CT and MRI by GH Physicians was reduced from baseline by 26%, and that baseline was already lower than the community.

My favorite themes for all of this work?  First – avoiding the cost of poor quality.  There is a lot of skepticism about the impact of improved quality on costs – some believing that underuse of expensive interventions is the main quality gap.  If we focus on value we see that first time quality and involving patient values in care decisions can lead to both better care and lower costs.

Second – Group Health staff are remarkable, and we work in what is essentially an incubator for innovation.  And it is innovation for patients’ sake, rather than just toying around with the next cool thing.  For any innovation to matter, it has to scale and be integrated into a larger story.  that takes both flexibility and standardization, two things that are easily seen as opposing values.  But it can work.

It is good to be us!

February 23, 2011

Health Reform Overview

Filed under: Uncategorized — Matt Handley @ 8:47 am

I wanted to share a great presentation that Len Nichols, health economist extraordinaire, gave at our medical group’s annual meeting.

No slides (which make it even more entertaining), but an engaging speaker.  A pragmatic guy who is close to the debates in DC, and great at making clear the basic issues confronting us.

You can watch the video here.

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